Provider Demographics
NPI:1245618396
Name:MORENO, ESMERALDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ESMERALDA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 83 BOX 6184
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-9723
Mailing Address - Country:US
Mailing Address - Phone:704-852-2403
Mailing Address - Fax:
Practice Address - Street 1:HC 83 BOX 6184
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-9723
Practice Address - Country:US
Practice Address - Phone:704-852-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE69635585OtherPCA CERTIFICATE
PR1988OtherPUERTO RICO GOVERMENT, DEPARTMENT OF HEALTH